Buoyant Democrats Unveil Health Care Legislation

WASHINGTON — House Democrats on Thursday unveiled their bill to remake the health care system and said they had the votes to pass it. But Republicans said gimmicks had been used to hide the measure’s long-term costs.

The bill is similar in size and scope to one taking shape in the Senate, where Democrats’ control is more tenuous and the outcome less certain.

With introduction of the bill, both houses of Congress are now poised for a momentous floor debate on the legislation, which would guarantee health benefits for millions of people now uninsured.

“We are about to deliver on the promise of making affordable, quality health care available for all Americans,” Speaker Nancy Pelosi declared at an outdoor rally on the west side of the Capitol.

The 83-year-old dean of the House, Representative John D. Dingell of Michigan, stole the show with a combative speech in which he attacked insurance companies and Republicans, who have been warning that the legislation would slash Medicare.

By expanding coverage and reining in health costs, Mr. Dingell said, the bill would meet “the greatest humanitarian need this country confronts, and the greatest economic problem.”

The Congressional Budget Office said the House bill would provide coverage to 36 million people.

By the most commonly used yardstick, the bill would cost $1.05 trillion over 10 years, roughly $150 billion more than President Obama had said he wanted to spend on the legislation.

Even so, the budget office said that the costs would be fully offset by cuts in the growth of Medicare and by new fees and taxes on individuals, families and businesses. Thus, it said, the bill would reduce projected federal budget deficits by $104 billion over 10 years.

Mr. Obama welcomed the House bill as “a historic step forward” and said it met two important criteria. “It is fully paid for and will reduce the deficit in the long term,” he said.

The budget office said 18 million people — one-third of them illegal immigrants — would still be uninsured in 2019. In the decade after that, it said, the House bill “would slightly reduce federal budget deficits.”

Republicans seized on the overall price tag of more than $1 trillion to bolster their contention that the measure was too costly.

In a sign of the political sensitivity of the numbers, Democrats on Thursday focused attention on a lower figure, the $894 billion net cost of the insurance coverage provisions.

None of the cost estimates of the bill included provisions to increase Medicare payments to doctors. Those provisions, which would cost more than $200 billion over 10 years, were put into a separate bill, also introduced Thursday.

House Democrats said the health care overhaul legislation could reach the floor next week. “We will have the votes to pass it,” said Representative Allyson Y. Schwartz of Pennsylvania.

To secure additional votes, House Democratic leaders tweaked the bill in several ways: reducing the number of high-income people who would be hit by a new surtax; exempting more small business from a requirement to provide coverage; and stipulating that a new government insurance plan negotiate rates with doctors and hospitals, rather than using Medicare rates set by the government.

Republicans said the 1,990-page bill would saddle the government with huge new financial obligations. With Medicare’s hospital trust fund projected to run out of money in eight years, they said, the government cannot afford the commitments it has.

The House Republican leader, Representative John A. Boehner of Ohio, denounced the bill as “costly and unsustainable.”

“Instead of listening to the American people,” Mr. Boehner said, “Democrats hid behind closed doors and came back with a bill designed to appease the liberal special interests.”

The Congressional Budget Office hinted that the savings in the House bill might not be achieved.

“Medicare spending under the bill would increase at an average annual rate of roughly 6 percent during the next two decades — well below the roughly 8 percent annual growth rate of the past two decades, despite a growing number of Medicare beneficiaries as the baby boom generation retires,” the budget office said.

A major point of contention between the House and the Senate is how to pay for the new coverage, to be provided by expanding eligibility for Medicaid and by subsidizing insurance for low- and middle-income people.

The Senate bill would impose an excise tax on high-premium insurance policies provided by employers. The House bill would impose a surtax on high-income people — couples with adjusted gross incomes over $1 million a year and individuals over $500,000.

Congressional tax analysts said the surtax would raise $460 billion over 10 years. As originally proposed, the surtax had thresholds of $350,000 for couples and $280,000 for individuals.

Representative Gerald E. Connolly, Democrat of Virginia, who represents one of the nation’s most affluent districts, said he and other freshmen had “worked awfully hard” to secure the change in the surtax.

Senators of both parties dislike the surtax. But labor unions oppose the tax on “Cadillac health plans,” the biggest revenue-raiser in the Senate bill.

The House bill includes a new provision that would require the secretary of health and human services to negotiate drug prices on behalf of Medicare beneficiaries. The proposal is anathema to pharmaceutical companies.

Undaunted by the August uproar over “death panels,” House Democrats would authorize Medicare to pay doctors for providing advice to patients on end-of-life care. The new bill says such consultations are “completely optional.”

The bill would require most Americans to obtain insurance and would require employers to provide coverage to workers or pay a penalty. Small businesses would be exempt from the employer mandate if they had payrolls of less than $500,000 a year, double the threshold in the Democrats’ original bill.

The budget office estimated that six million people would sign up for the public insurance plan.

But the budget office said the premiums in the government plan would be “somewhat higher than the average premiums” charged by private insurers, in part because the public plan would probably attract less healthy people and would be less aggressive in managing care.

In the House bill, as in the Senate bill, insurers would have to accept all applicants, could not limit coverage for pre-existing medical conditions and could not charge higher premiums because a person was sick.

Under a new provision of the House bill, children could stay on their parents’ insurance through the age of 26. A bill approved by the Senate health committee offers a similar guarantee for children through age 25.

A version of this article appears in print on October 30, 2009, on page A20 of the New York edition with the headline: Buoyant House Democrats Unveil Overhaul Bill. Order Reprints|Today's Paper|Subscribe